There are many different types of medical information that are routinely collected when a patient has an emergency or non-emergency medical problem, or visits a provider for a routine visit or annual physical. The medical information includes such information as current symptoms the patient is feeling, any medication the patient is currently taking, any past medical problems or surgeries the patient has, known allergies, family history, prescribed medications, etc.
Such medical information is typically recorded manually on paper forms by medical staff, nurses and/or providers. The medical information may also be dictated by a provider and later transcribed to another form by a medical transcriptionist.
The American Medical Association (“AMA”) has developed a system of codes for medical and surgical procedures, diagnostic tests, laboratory studies, and other provider medical services rendered to patients. This system of codes is referred to as Current Procedural Terminology, (“CPT”) codes. CPT codes provide a uniform language that details medical, surgical, and diagnostic services utilized by providers to communicate to third-party payors for the services that are rendered.
The CPT codes were first developed by the AMA in 1966. Each year, an annual publication is prepared by the AMA that includes CPT code changes corresponding with updates in medical technology and practice. The 2003 version of CPT codes, for example, CPT 2003, includes over 8,000 codes and descriptors. The CPT code set also includes a set of modifiers that may be used to further define CPT codes.
Evaluation and Management (E/M) codes are a sub-set of the CPT codes that are used to describe a patient's encounter in a provider's office, hospital or other medical setting. E/M codes are used to describe the level of care a provider renders to a patient.
The CPT and E/M codes are assigned numeric codes that used to classify the information, categorize and organize the information and used to generate revenue for the organization that employs the medical personnel. The numeric codes may also include codes used by insurance companies or other types of organizations such as health organizations such as those responsible for communicable diseases. Additional information on the AMA CPT and E/M codes can be obtained on the Internet at the Universal Resource Locator (“URL”) “www.ama-assn.org.”
The Health Care Finance Administration (“HCFA”), a U.S. government agency responsible for the operation of oversight of medical insurance programs such as Medicare and Medicaid, has also developed a set of medical codes and modifiers. The HCFA developed a set of medical codes called Health Care Procedural Coding System (“HCPCS”) codes to help relate CPT codes to medical billing. The HCFA was renamed the Centers for Medicare & Medicaid Services (CMS) on Jun. 14, 2001. Additional information on the HCFA HCPCS codes can be found on the Internet at the URL “cms.hhs.gov.”
In addition, the World Health Organization (“WHO”) also developed a similar set of codes to identify medical diagnoses, conditions and injuries. These codes are called International Classification of Diseases 9th edition Clinical Modification (“ICD-9”) codes and International Classifications 10th edition Clinical Modification (“ICD-10”) can be found on the internet at the URL “www.who.org”. ICD-10 codes for both diagnoses and procedures have been developed, but are not yet used in the USA.
Accurate and proper coding of medical information is important because it helps determine financial reimbursement for physician services. It is also important to ensure compliance with state and federal regulations as well as help protect physicians from the financial and legal ramifications of government, insurance company and other types of audits.
There are many problems associated with the collection and recording medical information. One problem is that incorrect medical coding creates both a revenue generation problem and a compliance problem for many physician practices.
For example, one study by Mitchell S. King, Lisa Sharp, and Martin S. Lipsky, entitled “Accuracy of CPT evaluation and management coding by family physicians,” and published in the Journal of American Board of Family Practice 14(3):184-192, 2001, has shown that family physicians tend to generate lower-level E/M codes for established patients, thereby “undercoding” the established patient visit. The undercoding results in a loss of potential revenues. Investigative agencies may also classify this practice as fraudulent, in that it may be construed to indicate that the provider is reducing fees by undercoding, and thereby attempting to entice patients to visit more frequently.
These same family physicians also tend to generate higher-level E/M codes than necessary for new patients, thereby “overcoding” the new patient visit. This results in rejection of insurance payments and could result in loss of revenue, insurance audits and potential prosecution under the Federal False Claims Act (“FFCA”), 31 U.S.C. 3729 or other Federal and state laws used prevent fraudulent insurance claims.
Another problem is that incorrect or improper coding of medical information could result in non-compliance with the Health Insurance Portability and Accountability Act (“HIPAA”) 42 U.S.C. 1320d, et. seq. and other Federal and state laws enacted to protect privacy.
Another problem is that medical organizations use many different types of medical codes from many different types of medical organizations on many different types of proprietary and public medical forms. The medical information is typically manually re-handled several times by several different types of people (e.g., providers, nurses, medical billing specialist, etc.) with different expertise levels with respect to coding of medical information. This handling may introduce errors for the coding of medical information at many different levels.
Another problem is that the medical information is often manually entered into a data processing system. A medical technician with knowledge of medical information and medical codes must process the information to assign the proper codes. As was described above, there are typically multiple sets of medical codes such as those used for diagnosis, billing, insurance, etc. that are routinely used and changed on a periodic basis. This may also introduce errors for the coding of medical information at many different levels.
Another problem is that it typically takes a significant amount of time to process medical information and create the proper medical codes from a patient encounter. This often leads to a very slow revenue stream for physicians and a large amount of frustration for patients.
There have been attempts to solve one or more of the problems associated with coding medical information. For example, U.S. Pat. No. 6,529,876 to Dart et al. entitled “Electronic template medical records coding system” describes a method and a computer program for use by health care providers for the production of accurate billing coding for care entered using established E/M codes.
U.S. Pat. No. 6,393,404 to Waters, et al. entitled “System and method for optimizing medical diagnosis, procedures and claims using a structured search space” describes a system and method for optimizing medical diagnosis, procedures and reimbursement claims using a structured search space.
U.S. Pat. No. 6,208,973 to Boyer, et al. entitled “Point of service third party financial management vehicle for the healthcare industry” describes a point of service third party adjudicated payment system and method which provides for the creation of an adjudicated settlement transaction at a point of service which designates the portion of the service to be paid by the third party payor and the portion to be paid by the customer.
U.S. Pat. No. 5,483,443 to Milstein, et al. entitled “Method for computing current procedural terminology codes from physician generated documentation”describes a process for calculating a Current Procedural Terminology (“CPT”) code from input received from a physician or other medical professional.
However, these inventions do not solve all of the problems associated with coding medical information. Thus, it would be desirable to help reduce the complexity of collecting patient encounter information and allow easy automated collection, processing and recording of medical information codes such as diagnosis codes, billing codes, insurance codes, etc. It is also desirable to provide such medical codes in real-time during or shortly after an encounter with a patient.